Your biweekly premiums for 2017
Your premiums for medical, dental and vision care are made on a before-tax basis. This means your contributions are automatically
deducted from your paycheck before taxes are withheld. As a result, you save money on taxes.
Full-time employees – classified as 30 hours or more per week
CIGNA
Premium plan
CIGNA
Standard plan
Coverage level
Employee only
Employee/
spouse
Employee/
child(ren)
Family
Total cost
$326.97
$732.41
$683.35
$1,033.21
Minus NH dollars
-277.09
-566.11
-559.08
-815.28
Your net cost
$49.88
$166.30
$124.27
$217.93
Coverage level
Employee only
Employee/
spouse
Employee/
child(ren)
Family
Total cost
$301.48
$675.31
$630.08
$952.67
Minus NH dollars
-274.70
-556.84
-550.13
-802.82
Your net cost
$26.78
$118.47
$79.95
$149.85
Part-time employees – classified as 24 to 29 hours per week
Coverage level
Employee only
Employee/
spouse
Employee/
child(ren)
Family
Total cost
$326.97
$732.41
$683.35
$1,033.21
Minus NH dollars
-217.85
-449.09
-441.82
-646.70
Your net cost
$109.12
$283.32
$241.53
$386.51
Coverage level
Employee only
Employee/
spouse
Employee/
child(ren)
Family
Total cost
$301.48
$675.31
$630.08
$952.67
Minus NH dollars
-222.00
-452.74
-445.81
-652.86
Your net cost
$79.48
$222.57
$184.27
$299.81
Coverage level
Employee only
Employee/
spouse
Employee/
child(ren)
Family
Total cost
$16.45
$34.18
$35.55
$58.06
Minus NH dollars
-9.30
-11.19
-12.06
-26.92
Your net cost
$7.15
$22.99
$23.49
$31.14
Coverage level
Employee only
Employee/
spouse
Employee/
child(ren)
Family
Your cost
$4.48
$7.03
$7.19
$11.58
CIGNA
Premium plan
CIGNA
Standard plan
Dental
Vision
For 2017, your deductions will be taken over 26 pay periods.
Medical plans
Premium plan 2017
Standard plan 2017
Novant
Health
CIGNA
Out-ofNovant
Health
CIGNA Network Out-of-network
Medical
Network
Network
network
Network
Deductible — Copays do not apply to the deductible. Deductibles cross-accumulate.
Employee only
$680
$1,925
$1,925
$850
$2,200
$2,200
Employee/child(ren)
$1,000
$2,900
$2,900
$1,275
$3,300
$3,300
Employee/spouse
$1,200
$3,400
$3,400
$1,500
$3,850
$3,850
Employee/family
$1,360
$3,850
$3,850
$1,700
$4,400
$4,400
Annual maximum
None
None
Lifetime maximum
Unlimited
Unlimited
Out-of-pocket maximum — Includes deductible, coinsurance and copays. All out-of-pocket tiers cross-accumulate. Medical and pharmacy
OOP are separate limits.
Employee only
$2,550
$3,600
$6,700
$4,200
$4,700
$7,800
Employee/child(ren)
$4,000
$5,600
$8,700
$6,500
$7,300
$10,400
Employee/spouse
$4,500
$6,300
$9,400
$7,400
$8,200
$11,300
Employee/family
$5,100
$7,200
$10,300
$8,400
$9,400
$12,500
Medical OOP limit any
$2,550
$3,600
N/A
$4,200
$4,700
N/A
one member
Medical and pharmacy limit
$4,150
$5,200
N/A
$5,800
$6,300
N/A
any one member
Fixed with
Fixed with
Wellness
Fixed with
Fixed with
Wellness
Employer-funded HRA
salary
salary
incentive up
salary
salary
incentive
<$150,000
>$150,000
to
<$150,000
>$150,000
up to
$0
$0
$900
$0
$0
$900
Employee only
Employee/child(ren)
$375
$0
$900
$0
$0
$900
Employee/spouse
$450
$0
$1,175
$0
$0
$1,175
Employee/family
$750
$0
$1,175
$0
$0
$1,175
All coinsurance amounts in-network and out-of-network are after the calendar year deductible, except where noted.
Novant Health
CIGNA
Out-ofNovant Health
CIGNA Network Out-of-network
Services
Network
Network
network
Network
Hospital inpatient services
5%
20%
40%
10%
25%
40%
Hospital outpatient services
5%
20%
40%
10%
25%
40%
Physician inpatient visits
5%
20%
40%
10%
25%
40%
Physician surgery, office
$75
20%
40%
$85
25%
40%
Physician surgery, IP and OP
$100
20%
40%
$200
25%
40%
Hospital emergency room
15%
15%
15%
20%
20%
20%
Urgent care facility
$20
20%
40%
$35
25%
40%
PCP office services,
$10
20%
40%
$25
25%
40%
excluding surgery
Specialist office services,
$50
20%
40%
$65
25%
40%
excluding surgery
X-rays and lab services,
5% no
20%
40%
10% no
25%
40%
including interpretation at
deductible*
deductible*
office or OP lab facility
Advanced radiology (MRI,
$125
20%
40%
$200
25%
40%
PET, CT), office
Anesthesia (IP or OP)
5%*
20%
40%
10%*
25%
40%
Preventive care
$0
$0
40%
$0
$0
40%
Hospital IP MH and SA
5%
20%
40%
10%
25%
40%
Physician office MH and SA
$10
20%
40%
$25
25%
40%
ABA therapy from
5%
20%
40%
10%
25%
40%
licensed/credentialed
providers
Maternity, hospital
5%
20%
40%
10%
25%
40%
Maternity, physician global
$100
20%
40%
$200
25%
40%
*Not all hospital-based providers at Novant Health facilities are in the Novant Health Network, so you will receive the CIGNA network benefit if the hospital-based provider is
not in the Novant Health Network. Novant Health is seeking to expand the number of hospital-based providers in the Novant Health Network.
myCIGNAplans.com UserID: NovantHealth2017 password: cigna (case sensitive)
Pharmacy benefits all plans
OptumRx pharmacy benefits are the same for both of the CIGNA plans. Prescription drug benefits are provided through OptumRx. Call
toll-free 1-866-230-8130. We will now offer the Optum premium formulary, which includes some changes. Certain covered drugs will be
replaced by clinically appropriate alternatives. Those affected by this change will receive a mailing from Optum describing the alternative drugs.
Pharmacy
Novant Health retail
pharmacies up to 30-day
supply
Deductible - Applies to RX OOP
None
Tier 1 – generic
Tier 2 – preferred brands
Tier 3 – brands
Tier 4 – value specialty
Tier 5 – preferred specialty
Tier 6 – non-preferred specialty
OOP maximum per claim
$5 (minimum $3)
$25
$45
$70
$100
$200
N/A
Non-Novant Health retail
pharmacies up to
30-day supply
$150 applies to
brand drugs
$10 (minimum $3)
$30 + 20%
$55 + 40%
Not covered
Not covered
Not covered
$145
Novant Health home delivery
up to
90-day supply
None
$12 (minimum $7)
$65
$135
$70 (30-day limit)
$100 (30-day limit)
$200 (30-day limit)
N/A
Mandatory generics with a DAW waiver. Difference between cost of brand and generic is not covered under the copay limit or the
out-of-pocket limit. Infertility drugs must be purchased from a Novant Health retail pharmacy or through Novant Health home delivery
and are limited to a 30-day supply. There is a $10,000 lifetime maximum benefit for drugs.
OOP maximum per calendar year – $1,600 employee only; $3,200 family ($1,600 OOP limit for any one member).